BLUNT INJURY ABDOMEN – AND THEIR IMPACT ON

ABDOMINAL VISCERAE

Dissertation submitted in partial fulfillment of the

Requirement for the award of the Degree of

M.S DEGREE EXAMINATION

GENERAL SURGERY

TIRUNELVELI

TIRUNELVELI MEDICAL COLLEGE

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY

CHENNAI, TAMILNADU

April 2012

  

CERTIFICATE This is to certify that the dissertation titled “BLUNT INJURY ABDOMEN

AND THEIR IMPACT ON ABDOMINAL VISCERAE” is the original work done

by Dr.J.KEVIN JOSEPH, Post Graduate in Department of General Surgery ,

Tirunelveli, to be Submitted to The TamilNadu Dr.M.G.R. Medical University,

Chennai – 32 towards the partial fulfillment of the requirement for the award of M.S.

Degree in General Surgery April 2012.

Prof. S.Soundararajan M.S Prof.V.Pandy M.S

Prof & HOD Unit Chief

Department of General Surgery Department of General Surgery

Tirunelveli Medical College Hospital Tirunelveli Medical College Hospital

Tirunelveli. Tirunelveli.

DEAN

Tirunelveli Medical College Hospital

Tirunelveli.

  

ACKNOWLEDGEMENT

I am deeply indebted to my beloved Teacher Professor.

S.Soundararajan Professor and Head of the Department of Surgery for his

constant guidance, encouragement and untiring help throughout the period of

this study.

I express my profound gratitude to Professor. V.PANDY, M.S.,

Professor. S. SURESH, M.S., for their constant guidance and suggestions

throughout my study period.

I am very thankful to assistant professor DR. S. AMALAN M.S , DR S.

SENTHIL ARUMUGAM , M.S. , Dr.Rakesh Fernando , Dr.Sivanupandian

for their kind help and suggestions.

I express my sincere gratitude to former professor and HOD

Dr.Jeyakumar Sagayam for his constant motivation and guidance

throughout my career

I thank the DEAN, TIRUNELVELI MEDICAL COLLEGE for

permitting me to use the Hospital facilities for my study.

  

CONTENTS

No CHAPTER PAGE NO.

1. Introduction 1

2. Aim of the study 2

3. Review of Literature 3

4. Materials and Methods 39

5. Observation 40

6. Results 43

7. Discussion 52

8. Protocol for management 61

9. Conclusion 62

9. Bibliography 63

Proforma

Master chart

1  

INTRODUCTION

The care of the trauma patient is demanding and requires speed and

efficiency. Evaluating patients who had sustained blunt abdominal trauma

remains one of the most challenging and resource intensive aspects of acute

trauma care.

Blunt abdominal trauma is a leading cause of mortality and morbidity

among all age groups . Identification of serious intra abdominal pathology is

often challenging .Many injuries do not manifest during the initial assessment

and treatment period. Missed intra abdominal injuries and concealed

hemorrhage are the cause of increased mortality and morbidity especially in

patients who survive the initial phase after an injury.

Physical signs are also often unreliable due to

a) Associated injuries may divert the focus from abdomen and it may be

diagnosed late

b) Frequent accompanying of alcohol intoxication confuses the diagnosis

Coordinating a trauma resuscitation demands a thorough pathophysiology

of trauma and shock , excellent clinical and diagnostic acumen , skill with

complex procedures, compassion and the ability to think rationally in a chaotic

milieu.

The number survivors of polytrauma have increased by 50% in recent

years and this is attributed to prompt medical treatment and rapid transfer of

patient’s to major trauma centers.

2  

AIM OF THE STUDY

1) To study the effect of blunt injury abdomen and their impact on

abdominal viscerae

2) To Study regarding the pattern of distribution as age , sex and organ

involvement

3) To evaluate various associated injuires in blunt injury abdomen

4) To focus on clinical signs & prioritize them as the prime tool in early

diagnosis

5) To Correlate the findings of abdominal sonography in trauma with

laparotomy findings

6) To analyze mortality with regarding to individual visceral injury

Inclusion Criteria’s:

Age limit >12 yrs

All patients with head injury

All patients with fractures

Exclusion Criteria:

Patients below 12 yrs of age

3  

REVIEW OF LITERATURE

Classification of abdominal Blunt injuries

a) Crush injury

b) Blast injury

c) Seatbelt syndrome

Contents Of Abdomen

A.Intra-Thoracic Abdomen: B.Pelvic Abdomen:

1.Diaphragm 1.Urinary Bladder

2.Liver 2.Urethra

3.Spleen 3.Rectum

4.Stomach 4.Small Intestine

5.Uterus , tubes , ovary

C.Retroperitoneal Abdomen: D.True Abdomen

1.Kidney 1.Small Intestine

2.Ureters 2.Large Intestine

3.Pancreas 3.Distended Bladder

4.Great Vessels 4.Gravid uterus

5.Duodenum

4  

Frequency Of injury in Blunt abdominal Trauma:

a. Spleen – 25%

b. Kidney- 12%

c. Intestine – 15%

d. Liver – 15%

e. Retroperitoneal haematoma – 13%

f. Mesentry – 5%

Management:

Pre Hospital Care:

a. Ensure adequately functioning airway \ I.V line

b. Apply sterile dressings

c. Don’t remove foreign body in trunk as major bleeding may follow after

removal.

d. Evisceration is best left undisturbed , except application of sterile

dressing.

Hospital Care and Diagnosis:

Important factors relevant to the care of a patient with blunt abdominal

trauma, specifically those involving motor vehicles, include the following:

• The extent of vehicular damage

• Whether the passenger space was intruded

• Whether a passenger died

• Whether the person was ejected from the vehicle

5  

• The role of safety devices such as seat belts and airbags

• The presence of alcohol or drug use

• The presence of a head or spinal cord injury

• If the patient has sustained rib fractures on the lower left chest there is

associated 20% splenic injury and associated rib fractures on lower right

chest there is 10% liver injury

• If patient has back pain pain associated with compression fracture of upper

limb or spinal region , it carries an associated 20% significant renal injury…

Physical Examination:

Primary survey

Resuscitation is performed concomitantly and continues as the physical

examination is completed. Priorities in resuscitation and diagnosis are

established on the basis of hemodynamic stability and the degree of injury. The

goal of the primary survey, as directed by the Advanced Trauma Life Support

(ATLS) protocol, is to identify and expediently treat life-threatening injuries.

The protocol includes the following:

• Airway, with cervical spine precautions

• Breathing

• Circulation

• Disability

• Exposure

6  

Secondary survey

After an appropriate primary survey and initiation of resuscitation,

attention should be focused on the secondary survey of the abdomen. The

secondary survey is the identification of all injuries via a head-to-toe

examination. For life-threatening injuries that necessitate emergency surgery, a

comprehensive secondary survey should be delayed until the patient has been

stabilized.

At the other end of the spectrum are victims of blunt trauma who have a

benign abdomen upon initial presentation. Many injuries initially are occult and

manifest over time. Frequent serial examinations, in conjunction with the

appropriate diagnostic studies, such as abdominal computed tomography (CT)

and bedside ultrasonography, are essential in any patient with a significant

mechanism of injury.

The evaluation of a patient with blunt abdominal trauma must be

accomplished with the entire patient in mind, with all injuries prioritized

accordingly. This implies that injuries involving the head, the respiratory

system, or the cardiovascular system may take precedence over an abdominal

injury.

The abdomen should neither be ignored nor be the sole focus of the

treating clinician and surgeon. In an unstable patient, the question of abdominal

involvement must be expediently addressed. This is accomplished by

identifying free intra-abdominal fluid with diagnostic peritoneal lavage (DPL)

7  

or focused assessment with sonography for trauma (FAST). The objective is

rapid identification of those patients who need a laparotomy.

The initial clinical assessment of patients with blunt abdominal trauma is

often difficult and notably inaccurate. Associated injuries often cause tenderness

and spasms in the abdominal wall and make diagnosis difficult. Lower rib

fractures, pelvic fractures, and abdominal wall contusions may mimic the signs

of peritonitis.

In general, accuracy increases if the patient is reevaluated repeatedly and

at frequent intervals. However, repeated examinations may not be feasible in

patients who need general anesthesia and surgery for other injuries. The greatest

compromise of the physical examination occurs in the setting of neurologic

dysfunction, which may be caused by head injury or substance abuse.

The most reliable signs and symptoms in alert patients are pain,

tenderness, gastrointestinal hemorrhage, hypovolemia, and evidence of

peritoneal irritation. However, large amounts of blood can accumulate in the

peritoneal and pelvic cavities without any significant or early changes in the

physical examination findings.

The respiratory pattern should be observed because abdominal breathing

may indicate spinal cord injury. A sensory examination of the chest and

abdomen should be performed to evaluate the potential for spinal cord injury.

Spinal cord injury may interfere with the accurate assessment of the abdomen

by causing decreased or absent pain perception.

8  

The abdominal examination must be systematic. The abdomen is

inspected for abrasions or ecchymosis. Particular attention should be paid to

injury patterns that predict the potential for intra-abdominal trauma (eg, lap belt

abrasions, steering wheel–shaped contusions). In most studies, lap belt marks

have been correlated with rupture of the small intestine and an increased

incidence of other intra-abdominal injuries.

Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus

(Cullen sign) indicates retroperitoneal hemorrhage, but this is usually delayed

for several hours to days.

Visual inspection for abdominal distention, which may be due to pneumo

peritoneum, gastric dilatation secondary to assisted ventilation or swallowing of

air, or ileus produced by peritoneal irritation, is important.

Auscultation of bowel sounds in the thorax may indicate the presence of a

diaphragmatic injury. Abdominal bruit may indicate underlying vascular disease

or traumatic arteriovenous fistula.

Palpation may reveal local or generalized tenderness, guarding, rigidity,

or rebound tenderness, which suggests peritoneal injury. Such signs appearing

soon after an injury suggest leakage of intestinal content. Peritonitis due to

intra-abdominal hemorrhage may take several hours to develop.

Fullness and doughy consistency on palpation may indicate intra-

abdominal hemorrhage. Crepitation or instability of the lower thoracic cage

9  

indicates the potential for splenic or hepatic injuries associated with lower rib

injuries.

Tenderness on percussion constitutes a peritoneal sign. Tenderness

mandates further evaluation and probably surgical consultation.

Rectal and bimanual vaginal pelvic examinations should be performed. A

rectal examination should be done to search for evidence of bony penetration

resulting from a pelvic fracture, and the stool should be evaluated for gross or

occult blood. The evaluation of rectal tone is important for determining the

patient’s neurologic status, and palpation of a high-riding prostate suggests

urethral injury.

The genitals and perineum should be examined for soft tissue injuries,

bleeding, and hematoma. Pelvic instability indicates the potential for lower

urinary tract injury, as well as pelvic and retroperitoneal hematoma. Open pelvic

fractures are associated with a mortality rate exceeding 50%.

A nasogastric tube should be placed routinely (in the absence of

contraindications, eg, basilar skull fracture) to decompress the stomach and to

assess for the presence of blood. If the patient has evidence of a maxillofacial

injury, an orogastric tube is preferred.

As the assessment continues, a Foley catheter is placed and a sample of

urine is sent for analysis for microscopic hematuria. If injury to the urethra or

bladder is suggested because of an associated pelvic fracture, then a retrograde

urethrogram is performed before catheterization.

10  

Tertiary survey

The concept of the tertiary trauma survey was first introduced by

Enderson et al to assist in the diagnosis of any injuries that may have been

missed during the primary and secondary surveys. The tertiary survey involves

a repetition of the primary and secondary surveys and a revision of all

laboratory and radiographic studies. In a study, a tertiary trauma survey detected

56% of injuries missed during the initial assessment within 24 hours of

admission.

The most important initial concern in the evaluation of a patient with

blunt abdominal trauma is an assessment of hemodynamic stability. In the

hemodynamically unstable patient, a rapid evaluation must be made regarding

the presence of hemoperitoneum. This can be accomplished by means of

diagnostic peritoneal lavage (DPL) or the focused assessment with sonography

for trauma (FAST). Radiographic studies of the abdomen are indicated in stable

patients when the physical examination findings are inconclusive.

Blood Studies:

Complete blood count:

The presence of massive hemorrhage is usually obvious from

hemodynamic parameters, and an abnormal hematocrit value merely confirms

the diagnosis. Normal hemoglobin and hematocrit results do not rule out

significant hemorrhage. Patients bleed whole blood. Until blood volume is

replaced with crystalloid solution or hormonal effects (eg, adrenocorticotropic

11  

hormone [ACTH], aldosterone, antidiuretic hormone [ADH]) and transcapillary

refill occurs, anemia may not develop.

Bedside diagnostic testing with rapid hemoglobin or hematocrit machines

may quickly identify patients who have physiologically significant volume

deficits and hemodilution. Reported hemoglobin from ABG measurements also

may be useful in identifying anemia. Some studies have correlated a low initial

hematocrit (ie, < 30%) with significant injuries.

Do not withhold transfusion in patients who have relatively normal

hematocrit results (ie, >30%) but have evidence of clinical shock, serious

injuries (eg, open-book pelvic fracture), or significant ongoing blood loss.

Hemodynamic instability in an adult despite the administration of 2 L of fluid

indicates ongoing blood loss and is an indication for immediate blood

transfusion. Use platelet transfusions to treat patients with thrombocytopenia

(ie, platelet count < 50,000/µL) and ongoing hemorrhage.

An elevated white blood cell (WBC) count on admission is nonspecific

and does not predict the presence of a hollow viscus injury (HVI). The

diagnostic value of serial WBC counts for predicting HVI within the first 24

hours after trauma is very limited.

Liver function tests

Liver function tests (LFTs) may be useful in the patient with blunt

abdominal trauma; however, test findings may be elevated for several reasons

(eg, alcohol abuse). One study has shown that an aspartate aminotransferase

12  

(AST) or alanine aminotransferase (ALT) level more than 130 U corresponds

with significant hepatic injury. Lactate dehydrogenase (LDH) and bilirubin

levels are not specific indicators of hepatic trauma.

Serum amylase or lipase measurements

The serum lipase or amylase level is neither sensitive nor specific as a

marker for major pancreatic or enteric injury. Normal levels do not exclude a

major pancreatic injury. Elevated levels may be caused by injuries to the head

and face or by an assortment of nontraumatic causes (eg, alcohol, narcotics,

various other drugs). Amylase or lipase levels may be elevated because of

pancreatic ischemia caused by the systemic hypotension that accompanies

trauma.

However, persistent hyperamylasemia or hyperlipasemia (eg, abnormal

elevation 3-6 hours after trauma) should raise the suggestion of significant intra-

abdominal injury and is an indication for aggressive radiographic and surgical

investigation.

Blood typing, screening, and cross-matching

Blood from all trauma patients with suspected blunt abdominal injury

should be screened and typed. If an injury is identified, this practice greatly

reduces the time required for cross-matching. An initial cross-match should be

performed on a minimum of 4-6 units for those patients with clear evidence of

abdominal injury and hemodynamic instability. Until cross-matched blood is

available, O-negative or type-specific blood should be used.

13  

Drug and alcohol screening

Perform drug and alcohol screens on trauma patients who have alterations

in their level of consciousness. Breath or blood testing may quantify alcohol

level.

Urine Studies

Indications for diagnostic urinalysis include significant trauma to the

abdomen and/or flank, gross hematuria, microscopic hematuria in the setting of

hypotension, and a significant deceleration mechanism.

Obtain a contrast nephrogram by utilizing intravenous pyelography (IVP)

or computed tomography (CT) scanning with intravenous (IV) contrast. Gross

hematuria indicates a workup that includes cystography and IVP or CT scanning

of the abdomen with contrast.

Perform a urine toxicologic screen as appropriate. Obtain a serum or

urine pregnancy test on all females of childbearing age.

Plain Radiography

Although their overall value in the evaluation of patients with blunt

abdominal trauma is limited, plain films can demonstrate numerous findings.

The chest radiograph may aid in the diagnosis of abdominal injuries such as

ruptured hemidiaphragm (eg, a nasogastric tube seen in the chest) or

pneumoperitoneum.

The pelvic or chest radiograph can demonstrate fractures of the

thoracolumbar spine. The presence of transverse fractures of the vertebral

14  

bodies (ie, Chance fractures) suggests a higher likelihood of blunt injuries to the

bowel. In addition, free intraperitoneal air, or trapped retroperitoneal air from

duodenal perforation, may be seen.

Ultrasonography

The use of diagnostic ultrasonography to evaluate a patient with blunt

trauma for abdominal injuries has been advocated since the 1970s. European

and Asian investigators have extensive experience with this technology and are

leaders in the use of ultrasound for the diagnosis of blunt abdominal trauma.

The first American report of physician-performed abdominal ultrasonography in

the evaluation of blunt abdominal trauma was published in 1992 by Tso and

colleagues.

Bedside ultrasonography is a rapid, portable, noninvasive, and accurate

examination that can be performed by emergency clinicians and trauma

surgeons to detect hemoperitoneum. In fact, in many medical centers, the FAST

examination has virtually replaced DPL as the procedure of choice in the

evaluation of hemodynamically unstable trauma patients.

The FAST examination is based on the assumption that all clinically

significant abdominal injuries are associated with hemoperitoneum. However,

the detection of free intraperitoneal fluid is based on factors such as the body

habitus, injury location, presence of clotted blood, position of the patient, and

amount of free fluid present.

15  

In a patient with isolated blunt abdominal trauma and multisystem

injuries, FAST performed by an experienced sonographer can rapidly identify

free intraperitoneal fluid (generally appearing as a black stripe). The sensitivity

for solid organ encapsulated injury is moderate in most studies. Hollow viscus

injury (HVI) rarely is identified; however, free fluid may be visualized. For

patients with persistent pain or tenderness or those developing peritoneal signs,

FAST may be considered as a complementary measure to CT scanning, DPL, or

exploration.

The minimum threshold for detecting hemoperitoneum is unknown and

remains a subject of interest. Kawaguchi and colleagues found that 70 mL of

blood could be detected,whereas Tiling et al found that 30 mL is the minimum

requirement for detection with ultrasonography. They also concluded that a

small anechoic stripe in the Morison pouch represents approximately 250 mL of

fluid, whereas 0.5-cm and 1-cm stripes represent approximately 500 mL and 1 L

of free fluid, respectively.

The current FAST examination protocol consists of 4 acoustic windows

with the patient supine. These windows are pericardiac, perihepatic, perisplenic,

and pelvic (known as the 4 P s). An examination is interpreted as positive if free

fluid is found in any of the 4 acoustic windows and as negative if no fluid is

seen. An examination is deemed indeterminate if any of the windows cannot be

adequately assessed.

16  

The pericardial window is obtained via a subcostal or transthoracic

approach. It provides a 4-chamber view of the heart and can detect the presence

of hemopericardium, which is demonstrated by the separation of the visceral

and parietal pericardial layers.

The perihepatic window yields views of portions of the liver, diaphragm,

and right kidney. It reveals fluid in the Morison pouch (see the images below),

the subphrenic space, and the right pleural space.

Blunt abdominal trauma. Normal Morison pouch (ie, no free fluid).

Blunt abdominal trauma. Free fluid in Morison pouch

The perisplenic window provides views of the spleen and the left kidney

and reveals fluid in the splenorenal recess (see the images below), the left

pleural space, and the subphrenic space. The pelvic window makes use of the

bladder as a sonographic window and thus is best accomplished while the

17  

patient has a full bladder. In males, free fluid is seen as an anechoic area

(sonographically black) in the rectovesicular pouch or cephalad to the bladder.

In females, fluid accumulates in the Douglas pouch, posterior to the uterus.

Blunt abdominal trauma. Normal splenorenal recess.

Blunt abdominal trauma. Free fluid in splenorenal recess.

FAST’s diagnostic accuracy generally is equal to that of DPL. Studies

demonstrate a degree of operator dependence; however, some studies have

shown that with a structured learning session, even novice operators can

identify free intra-abdominal fluid, especially if more than 500 mL of fluid is

present. Sensitivity and specificity of these studies range from 85% to 95%

As noted, FAST relies on hemoperitoneum to identify patients with injury. Chiu

and colleagues, in their study of 772 patients with blunt trauma undergoing

18  

FAST scans, reported 52 patients had an abdominal injury. Of the 52 patients,

15 (29%) had no hemoperitoneum on FAST or CT scan results. These findings

suggest that the reliance on hemoperitoneum as the sole indicator of abdominal

visceral injury limits the utility of FAST as a diagnostic screening tool in stable

patients with blunt abdominal trauma.

Rozycki et al studied 1540 patients and reported that ultrasonography was

the most sensitive and specific modality for the evaluation of hypotensive

patients with blunt abdominal trauma (sensitivity and specificity, 100%)

Hemodynamically stable patients with positive FAST results may require

a CT scan to better define the nature and extent of their injuries. Taking every

patient with a positive FAST result to the operating room may result in an

unacceptably high laparotomy rate.

Hemodynamically stable patients with negative FAST results require

close observation, serial abdominal examinations, and a follow-up FAST

examination. However, strongly consider performing a CT scan, especially if

the patient is intoxicated or has other associated injuries.

Hemodynamically unstable patients with negative FAST results are a

diagnostic challenge. Options include DPL, exploratory laparotomy, and,

possibly, a CT scan after aggressive resuscitation.

Computed Tomography

Although expensive and potentially time-consuming, CT scanning often

provides the most detailed images of traumatic pathology and may assist in

19  

determination of operative intervention.\CT remains the criterion standard for

the detection of solid organ injuries (see the image below). In addition, a CT

scan of the abdomen can reveal other associated injuries, notably vertebral and

pelvic fractures and injuries in the thoracic cavity.

Blunt abdominal trauma with liver laceration.

CT scanning, unlike DPL or FAST, has the capability to determine the

source of hemorrhage (see the image below). In addition, many retroperitoneal

injuries go unnoticed with DPL and FAST examinations.

Blunt abdominal trauma with splenic injury and hemoperitoneum.

Transport only hemodynamically stable patients to the CT scanner. When

performing CT scans, closely and carefully monitor vital signs for clinical

evidence of decompensation. Preliminary evidence suggests that a flat vena

20  

cava on CT scan is a marker for underresuscitation and may be correlated with

higher mortality and hemodynamic decompensation.

CT scans provide excellent imaging of the pancreas, duodenum, and

genitourinary system. The images can help quantitate the amount of blood in the

abdomen and can reveal individual organs with precision. The primary

advantage of CT scanning is its high specificity and use for guiding

nonoperative management of solid organ injuries.

Drawbacks of CT scanning relate to the need to transport the patient from

the trauma resuscitation area and the additional time required to perform CT

scanning compared to FAST or DPL.

In addition, CT scanning may miss injuries to the diaphragm and

perforations of the gastrointestinal (GI) tract, especially when performed soon

after the injury. Although some pancreatic injuries may be missed with a CT

scan performed soon after trauma, virtually all are identified if the scan is

repeated in 36-48 hours. For selected patients, endoscopic retrograde

cholangiopancreatography (ERCP) may complement CT scanning to rule out a

ductal injury.

Finally, CT scanning is relatively expensive and time consuming and

requires oral or intravenous (IV) contrast, which may cause adverse reactions.

The best CT imagery requires both oral and IV contrast. Some controversy has

arisen over the use of oral contrast and whether the additional information it

provides negates the drawbacks of increased time to administration and risk of

21  

aspiration. The value of oral contrast in diagnosing bowel injury has been

debated, but no definitive answer exists at this time.

Diagnostic Laparoscopy

The introduction of minimally invasive surgery has revolutionized many

surgical diagnostic protocols. In the late 1980s and early 1990s, there was

considerable interest in the use of laparoscopy for evaluation and management

of blunt and penetrating abdominal trauma. Subsequent studies, however,

revealed major limitations to this approach and cautioned against its widespread

use. The most important limitation is inability to reliably identify hollow viscus

and retroperitoneal injuries, even in the hands of experienced laparoscopists.

Diagnostic laparoscopy involves placing a subumbilical or subcostal trocar for

the introduction of the laparoscope and creating other ports for retractors,

clamps, and other tools necessary for visualization of the repair.

Diagnostic laparoscopy has been most useful in the evaluation of possible

diaphragmatic injuries, especially in penetrating thoracoabdominal injuries on

the left side.In blunt trauma, it has no clear advantages over less invasive

modalities such as DPL and CT scanning; furthermore, complications can result

from trocar misplacement.

Diagnostic Peritoneal Lavage

The idea of evaluating the abdomen by analyzing its contents was first

used in the diagnosis of acute abdominal conditions. In 1906, Salomon

described the passage of a urethral catheter by means of a trocar inserted

22  

through the abdominal wall to obtain samples of peritoneal fluid with the aim of

establishing the diagnosis of peritonitis from infectious agents (eg,

pneumococcal or tuberculous organisms). This technique has since been refined

and is now known as abdominal paracentesis.

In 1926, Neuhof and Cohen described the sampling of peritoneal fluid in

cases of acute pancreatitis and blunt abdominal trauma by passing a spinal

needle through the abdominal wall. In 1965, Root et al reported the use of

percutaneous DPL in patients who had sustained blunt abdominal trauma.

DPL is used as a method of rapidly determining the presence of intraperitoneal

blood. It is particularly useful if the history and abdominal examination of an

unstable patient with multisystem injuries are either unreliable (eg, because of

head injury, alcohol, or drug intoxication) or equivocal (eg, because of lower rib

fractures, pelvic fractures, or confounding clinical examination).

DPL is also useful for patients in whom serial abdominal examinations

cannot be performed (eg, those in an angiographic suite or operating room

during emergency orthopedic or neurosurgical procedures).

INDICATIONS:

• Hemodynamically unstable patients with negative FAST \CT

• Patients with a spinal cord injury

• Those with multiple injuries and unexplained shock

• Obtunded patients with a possible abdominal injury

• Intoxicated patients in whom abdominal injury is suggested

23  

• Patients with potential intra-abdominal injury who will undergo

prolonged anesthesia for another procedure.

Contraindications:

Absolute contraindication :

The obvious need for laparotomy.

Relative contraindication:

Morbid obesity

History of multiple abdominal surgeries

Pregnancy.

Various methods of introducing the catheter into the peritoneal space have been

described.

These include the open, semiopen, and closed methods.

The open method requires an infraumbilical skin incision that is extended

to and through the linea alba. (In pregnant patients or in patients with particular

risk for potential pelvic hematoma, the incision should be placed superior to the

umbilicus.) The peritoneum is opened, and the catheter is inserted under direct

visualization.

The semiopen method is identical, except that the peritoneum is not

opened and the catheter is delivered percutaneously through the peritoneum into

the peritoneal cavity.

The closed technique requires the catheter to be inserted blindly through

the skin, subcutaneous tissue, linea alba, and peritoneum.

24  

The closed and semiopen techniques at the infraumbilical site are

preferred at most centers. The fully open method is the most technically

demanding and is restricted to those situations in which the closed or semiopen

technique is unsuccessful or is deemed unsafe (eg, patients with pelvic fractures,

pregnancy, obesity, or prior abdominal operations).

PROCEDURE:

After insertion of the catheter into the peritoneum, attempt to aspirate free

intraperitoneal blood (at least 15-20 mL).

Results are considered positive in a blunt trauma patient if ,

10 mL of grossly bloody aspirate is obtained before infusion of the

lavage fluid

If the siphoned lavage fluid contains more than 100,000 red blood cells

(RBCs)/µL, more than 500 white blood cells (WBCs)/µL,

Elevated amylase content,

Bile, bacteria, vegetable matter, or urine.

Only approximately 30 mL of blood is needed in the peritoneum to

produce a microscopically positive DPL result.

If findings are negative, infuse 1 L of crystalloid solution (eg, lactated

Ringer solution) into the peritoneum. Then, allow this fluid to drain by gravity,

and ensure that laboratory analysis is performed.

Complications :

Bleeding from the incision and catheter insertion,

25  

Infection (ie, wound, peritoneal),

Injury to intra-abdominal structures (eg, urinary bladder, small bowel,

uterus).

These complications may increase the possibility of false-positive studies

Bleeding from the incision, dissection, or catheter insertion can cause

false-positive results that may lead to unnecessary laparotomy. Achieve

appropriate hemostasis prior to entering the peritoneum and placing the

catheter.

False-positive DPL results can occur if an infraumbilical approach is used

in a patient with a pelvic fracture. A pelvic x-ray film should be obtained prior

to performing DPL if a pelvic fracture is suggested. Before DPL is attempted,

the urinary bladder and stomach should be decompressed.

DPL has been shown in some studies to have a diagnostic accuracy of

98-100%, a sensitivity of 98-100%, and a specificity of 90-96%. It has some

advantages, including high sensitivity, rapidity, and immediate interpretation.

The main limitations of DPL include its potential for iatrogenic abdominal

injury and its high sensitivity, which can lead to nontherapeutic laparotomies.

With the availability of fast, noninvasive, and better imaging modalities

(eg, FAST, CT scanning), the role of DPL is now limited to the evaluation of

unstable trauma patients in whom FAST results are negative or inconclusive. In

some contexts, DPL may be complemented with a CT scan if the patient has

positive lavage results but stabilizes.

26  

MANAGEMENT OF SPECIFIC INJURIES AT

LAPAROTOMY

PATHOPHYSIOLOGY OF BLUNT INJURIES

Management of patient with blunt abdominal trauma requires and

understanding of the injury mechanism. In general injuries can be classified

as high energy or low energy. Several pathophysiogical processes involved are

1) Sudden pronounced rise in intra abdominal pressure causing burst injury

of solid organs or rupture of hollow viscus.

2) Compression of abdominal viscera the applied force to the anterior wall

to the posterior thoracic cage or vertebral column.

3) Abrupt, shearing forces can cause tear of organs or vascular pedicles

SPLENIC INJURIES

Organ most frequently injured in blunt abdominal trauma

a. Compression may occur between the anterior wall and posterior rib cage

b. Clinical picture includes Left upper quadrant pain , Signs of hypovolumia ,

Pain in the left shoulder (Kehr’s Sign)

c. Xray features include-

Enlargement of splenic shadow ,

Medial displacement of gastric shadow ,

associated rib fractures..

27  

SPLENIC INJURY SCALE

GRADE INJURY DESCRIPTION

I Haematoma - Subcapsular, non expanding < 10 % surface area

Laceration - Capsular tear, non bleeding < 1cm Parenchymal

depth

II Haematoma - Subcapsular, non expanding 10-50% surface area

intra parenchymal non expanding < 2cm in

diameter

Laceration - Capsular tear, active bleeding

III Haematoma - Subcapsular > 50 % surface area or expanding

ruptured subcapsular haematoma, active bleeding

- Intra parenchymal haematoma > 2 cm or expanding

Laceration > 3 cm parenchymal depth or involving trabecular

Vessels.

IV Haematoma - Intraparenchymal haematoma with active

bleeding

Laceration - Laceration involving segmental or hilar vessels

producing major devascularisation (>25 % of

spleen)

28  

Splenic Salvage:

Adequate mobilization enhances success of salvage

Capsular tear-Topical hemostatic agents

Small lacerations- Interlocking sutures

Major laceration <50% - Segmental splenic resection

Splenic Salvage Should not be pursued:

If the patient has protracted hypotension

Undue delay is anticipated in repair of laceration

Patient has other severe injuries

Splenectomy Complications:

Left pleural effusion

Left lower lobe collapse

Post splenectomy sepsis

Liver Injuries:

Liver is the largest organ in the abdominal cavity .Due to its size injuries

sufficient to lacerate the liver are associated with injuries to other organs in

about 80% cases.Spontaneous hemostatic mechanism that characterize liver

tissue may contribute pervasive observation that 85% of liver injuries do not

bleed at time of laparotomy.

A patient who has history of being in shock at the scene following blunt

trauma should be suspected of having major liver trauma.

29  

X-Ray features:

Evidence of hemoperitoneum (Elevation of diaphragm)

Fracture lower ribs corresponding to right side

GRADE INJURIES DESCRIPTION

I Haematoma - Subcapsular, non expanding ,< 10 %

Surface area

Laceration - Capsular tear, non bleeding < 1 cm deep

II Haematoma - Subcapsular non expanding, 10-50 %

intraparenchymal, non expanding

Laceration - < 3m parenchymal depth < 10 cm in length

III Haematoma - Subcapsular > 50 % surface area, expanding

ruptured intra parenchymal, haematoma

with active bleeding.

Laceration - > 3 cm parenchymal depth.

IV Haematoma - Ruptured central haematoma

Laceration - Parenchymal disruption involving 25 to75%

Of hepatic lobe

V Laceration - Parenchymal destrucion > 75 % of hepatic

lobe

Most Liver injuries infact requires documentation and no drainage.

30  

Indications for laparotomy during the period of observation are

1. Deteriorating vital signs.

2. Infection

3. Progressive expansion of the haematoma.

General measures in Management:

Class I parenchymal Lacerations:

treated by compression for 5 to 10 minutes.

Topical agents. microfibrillar collagen and gel foam. can be used to stop

bleeding

Class II parenchymal lacerations:

Classically horizontal mattress sutures with 0 chromic catgut often

place with blunt needle is used

Class III & IV Lacerations:

Lacerations which continue to bleed despite initial management requires

tractotomy .The depth of wound are explored and specific blood vessels

and biliary radicals are individually suture ligated.

If bleeding continues still compression on porta hepatis (Pringle

manoeuvre)

When selective ligation fails ligation of hepatic artery is done . It

produces dramatic hemostasis without subsequent liver failure

Alternative is resectional debridement accompalisehed by finger fracture ,

removing the devitalized liver or portion of the segment

31  

Bleeding from Hepatic Veins:

Unilobular – Resection and debridement is sufficient

Bilobular – placement of intracaval shunt

Still uncontrollable packing of injury and resuscitation is appropriate

followed by subsequent removal of pack in 24-72 hours

Complications following liver injury:

Pulmonary complications

Coagulopathy

Jaundice

Biliary fistula

Hemobilia

DIC

DUODENAL INJURIES

These injuries are suspected if history of trunk injury or localized blow to

epigastrium with handle bars , steering wheel or fist. Failure to recognize this

injury is associated with high mortality and morbidity caused by abscess

formation and sepsis since it’s a retroperitoneal organ.

X-Ray features:

Obliteration of psoas shadow

Absence of air in duodenal bulb

Air in retroperitoneum

32  

CT with oral contrast is definite showing extravasation of dye..

Management:

Full inspection by taking down hepatic flexure of colon and performing a

kocher maneuver is mandatory….

Limited perforation or simple laceration within 6 hrs are treated by

primary closure , if more than 6 hrs has elapsed suture closure with tube

duodenostomy is indicated

If laceration is extensive Roux-en-Y jejuno duodenostomy is indicated

Distal duodenum (III &IV) parts injuries can be primarily closed if it

occurs within 6 hrs of injury , but if duration extends above 6 hrs

resection of III & IV parts and duodenal jejunostomy should be

performed.

Pancreatico duodenectomy is occasionally indicated for massive injury in

right upper quadrant cant be repaired usually due to devascularisation…

SMALL INTESTINE INJURIES

Crushing injury of the bowel between the spine and the blunt object such

as the steering wheel or handlebars

Deceleration shearing of the small bowel at fixed points such as

ileocaecal valve and around superior mesenteric artery

Closed loop rupture caused by increased intra-abdominal pressure.

33  

Antibiotics should be started preoperatively

At Laparotomy:

Significant bleeding must be first priority

Apply non-crushing clamps to prevent further leakage of small bowel

contents

Examine small bowel carefully from ligament of trietz to ileocaecal valve

Single holes can be closed without debridment

Transection of small bowel is debrided and closed in routine fashion and

mesenteric defect is to be closed

Complications:

Intra-abdominal abscess

Anastamotic leakage

Enterocutaneous fistula

Intestinal obstruction

34  

PANCRETIC INJURIES

Blunt trauma to the abdomen from a direct kick , blow or seat belt injury

may crush the pancreas over the vertebral column . The shared blood supply

between the pancreas and duodenum makes the likelihood of these two injuries

in combination very high

Persistant Amylasemia

Contrast duodenography revealing widening of C loop

Loss of psoas shadow , anterior displacement of stomach

Left pleural effusion

CLASSIFICATION OF PANCREATIC INJURIES

TYPE DEFINITIONS

I Contusion and laceration

II Distal transection or parenchymal

Injury with duct injury

III Proximal transection or parenchymal

Injury with probable duct injury

Management:

The entire pancreas should be visualized clearly .

Simple debridement

Injury to body and tail should be treated with partial resection

In patients with ductal transactions in the head, the treatment options are

1. Roux-en-y distal pancreatico jejunostomy

35  

2. Anterior Roux-en-y distal pancreatico jejunostomy.

3. Resection.

Complications:

• Pancreatic Fistula

• Abscess in lesser sac

• Pseudo pancreatic Cyst

RETRO-PERITONEAL HEMATOMAS

Retroperitoneum can be divided into three zones,

Zone 1 –Central

Zone 2 – Flank \ Peri nephric

Zone 3 – Pelvic

Management:

Zone 3 injuries will usually have associated pelvic injuires and so

exploration of these injuries are hazardous . Incision to peritoneum destroys the

tamponade effect so non operative management is the rule in zone 3 injuries .

Also discrete bleeding points can rarely be identified as there is catastrophic

bleeding.

Zone 2 injuries can be left alone if not expanding

Zone 1 injuries are always explored due to associated injury to major

vascular structures and viscera ( Pancreatico duodenal injuries)

36  

RENAL INJURIES

The kidney is the most common injured part of the Urinary Tract.

Classification:

MAJOR – 15% (Deep cortical \ Medullary lacerations , Large perinephric

hematomas,Vascular Injuries Of Vascular pedicle)

MINOR – Other Injuries

X-Ray:

a. Absent psoas muscle shadow

b. Altered kidney outline

c. Ground glass appearance suggestive of either extravasation

of urine or haemoperiotoneum.

d. Associated bony injuries like rib fractures

IVU:

a. Delay in visualization of the contract.

b. Extravasation of the contract

c. Lack of continuous renal outline

d. Enlarged renal shadow.

A normal IVU in a patient with haematuria indicates minor renal

contusion

37  

MANAGEMENT:

Renal Injuries associated with blunt injury abdomen are usually not explored

unless they are pulsatile or expanding.

Shattered kidney is treated with nephrectomy to prevent haemorrhage.

Renal vein injury is repaied by venorrhaphy.

Renal artery injury is repaired by lateral arteriorrhaphy, arterial resection.

BLADDER INJURY

Majority of bladder injuries occur due to blunt abdominal trauma .

Bladder injury should be suspected strongly in persons with hematuria and

pelvic fractures.

Bladder rupture may be Extraperitoneal or Intraperitoneal

Diagnosis by IVU \ Cystography

Extra-Peritoneal Rupture:

• Non Operative management is the rule

• By prolonged Foleys catheter use

- If patient has no Intra-abdominal injuries

- No significant local hemorrhage

- No UTI

- Severe pelvic fractures \ massive Retro peritoneal bleeding

38  

Delayed repair can be contemplated once the retroperitoneal bleeding is

controlled and their condition is stabilized

Intra-Pertitoneal Rupture:

Transabdominal approach – Closure with SPC and drainage..

39  

MATERIALS AND METHODS

Thirty Four cases of blunt abdominal trauma admitted in all surgical units

at Tirunelveli Medical College Hospital, Tirunelveli during the period of

December 2010 to November 2011 were taken for this study.

The cases were selected in such a way that only those patients with

definitive history and clinical findings suggestive of injury to Viscerae which

were later confirmed by investigations, laparotomy and autopsy. Detailed

history regarding the mode and nature of injury were taken, The clinical features

were studies in details with special note to any associated injuries like head

injury, chest injury and fracture limbs. Basic investigations viz. blood Hb, blood

urea, blood sugar, serum creatinine and blood grouping were done in all cases.

Plain X-ray of the abdomen in erect posture was taken in most of the

cases expect in those who were admitted in a critically ill condition.

Radiographs of other parts were also taken to find out associated injuries.

Under aseptic precaution using sterile 18 G needle peritoneal tapping

done in all the four quadrants, in all patients with the history of blunt abdominal

trauma.

At laparotomy a systematic approach with examination of all intra

abdominal organs were made. After surgery the patients were continued on

nasogastric, aspiration, antibiotics.Postoperative complications were specifically

looked for, if present were treated appropriately.

40  

OBSERVATION

In our study conducted at Tirunelveli Medical college hospital for 34

cases of blunt injury abdomen , the following findings were noted,

Splenic Injuries 11 -32.35%

Liver injuries 08 - 23.52%

Bladder injury 04 -11.76%

Renal injury 04 -11.76%

Mesentery 03 -8.82%

Bowel perforation 04 -11.76%

At laparotomy the commonest organ injured in most of the series is

spleen ( Denver Hospital study, Herman Hospital )

Age wise the age group of 31-40 is most commonly affected 35% . S.C

Dwivedi et al and B.C. Jain et al reported similar results. This shows that

persons in the active period of life are more susceptible for accidents and

injuries.

Sex wise male affection rate is 94% . B.C. Jain et al and Connecticut

society of surgeons study on abdominal trauma reported similar results. This

increased incidence in males is probably due to outdoor nature of occupation

and aggressive behaviour in males.

Diagnostic Four quadrant aspiration was done in all cases , and it was

positive for presence of blood \ fluid in 29 cases 85.29%. Abdominal

paracentesis when positive is highly predictive of significant intraabdominal

41  

injuries but the accuracy varies from 50 % to 90 % in various studies, Authony

et al Showed 90 % accuracy.

All the cases were resuscitatied and subjected to FAST before exploratory

laparotomy . Of these there were 3 cases where the FAST findings did not

correlate with laparotomy findings .FAST missed a case of splenic laceration , a

case of Liver laceration , and there was a wrong interpretation of a case of Renal

injury having associated liver injury.

The incidence of False positive was 2.94% and the incidence of False

negative 5.88%.In cased of bladder injuries FAST revealed presence of clots

and mesenteric and bowel injuries it revealed presence of free fluid. Stritmatter

B. et al howed a sensitivity of 95.5 % and specificity of 97.5 % hence

ultrasonogram can be used as a initial imaging procedure.

Associated injuries include Rib fractures in 5 cases of liver lacertion

62.5% , 3 rib fractures in spleen 27.27% , 1 rib fracture in mesenteric contusion

33.33%. There is a 20 % chance of splenic injury and10 % chance of liver

injury with fracture ribs on the left or right lower six ribs (Graffin W.o et al ,

Moore E.E. )

Zone 2 RPH was present in all four cases of renal injury , the right kidney

was injured in 3 cases and the left in one case , Zone 3 RPH was present in a

case of mesenteric contusion.

# of both superior and inferior pubic rami was present in all four cases of

bladder injury

42  

# forearm was present in a case of mesenteric contusion , # tibia was

present in a case of ileal perforation.

In our study there was no incidence of simultaneous two solid organ

injury.

So the associated injuries include,

1.Rib # - 9 26.47%

2.RPH - 5 14.70%

3. superior and inferior pubic rami - 4 11.76%

4.# Tibia - 1 2.94%

5. # Forearm - 1 2.94%

Total no of death in our study was two cases , A case of Grade IV liver

laceration with massive hemoperitoneum and a case of Grade III laceration

spleen.The mortality rate is 6% . Herman Hospital study showed a mortality of

24%.

43  

RESULTS

AGE WISE INCIDENCE OF CASES

Sl No Age of the patient Number of cases

1 13 – 20 6

2 21 – 30 10

3 31 – 40 12

4 41 – 50 4

5 51 – 60 2

0

2

4

6

8

10

12

14

13 ‐ 20 21 ‐ 30 31 ‐ 40 41 ‐ 50 51 ‐ 60

Agewise incidence of cases

 

SEX

M

F

T

WISE IN

Num

SEX

Male

Female

Total

44 

NCIDENC

6%

mber Of MALE FEM

NO OF

32

2

34

CE OF CA

94%

CasesMALE

F CASES

ASES

S

45  

MODE OF INJURY

S. No Mode of injury No of cases

1 Road traffic accident 22

2 Fall from height 6

3 Bull Gore Injury 6

0 5 10 15 20 25

Bull Gore Injury

Fall From Height

Road Traffic Accident

Mode Of Injury

Bull Gore Injury

Fall From Height

Road Traffic Accident

46  

CLINICAL SIGNS

Clinical Signs Spleen Liver Renal Mesentry Bowel Bladder

Tenderness 9 7 4 2 4 4

Guarding /

Rigidity

5 4 1 1 4 1

Bowel Sounds

(+)

8 6 3 2 0 1

Pulse Rate

>100/Min

11 8 4 1 4 2

0

2

4

6

8

10

12

tenderness gaurding/ rigidity bowel sounds (+) pulse rate >100

CLINICAL SIGNS

spleen

liver

renal

mesentry

bowel

bladder

47  

HAEMODYNAMIC STABILITY

Organ

Injured

Unstable

Cases

Total No Of

Cases

Spleen 3 11

Liver 3 8

3 3

118

spleen liver

Haemodynamic stabilityunstable total cases

48  

ASSOCIATIED INJURIES

ORGAN

INJURED

TYPE OF ASSOCIATED

INJURY NO OF CASES

Spleen Fracture Of Ribs 3/11

Liver Fracture Of Ribs 5/8

Kidney Retro Peritoneal Haematoma 4/4

Bladder Fracture Suprapubic Rami 4/4

Retro Peritoneal Haematoma 1/4

Mesentry Retro Peritoneal Haematoma 1/4

0

2

4

6

8

10

12

14

16

SPLEEN LIVER KIDNEY BLADDER MESENTRY

NO OF CASES

ASSOCIATED INJURY

 

N

T

MO

No Of Dea

Total No O

Cases

6

94%

M

49 

ORTALIT

ath

Of

6%

ORTALI

TY

2

34

TY

No of deat

No of case

ths

es

50  

DIAGNOSTIC PARACENTESIS

ORGAN FREE FLUID (+) FREE FLUID (-)

Spleen 11 0

Liver 8 0

Kidney 2 2

Bladder 3 1

Bowel 4 0

Mesentry 1 3

0

2

4

6

8

10

12

spleen liver kidney bladder bowel mesentry

Free Fluid (‐)

Free fluid (+)

51  

USG CORELATION

ORGAN USG FINDING NO OF CASES

Spleen Laceration 10/11

Liver Laceration 7/8

Kidney contusion 4/4

Bladder Free fluid abdomen 4/4

Bowel Free fuid abdomen 4/4

0

5

10

15

20

25

spleen liver kidney bladder bowel

USG CORELATION

USG findings no of cases

52  

DISCUSSION

SPLENIC INJURY:

Spleen is the commonest organ injured following blunt abdominal

trauma. In our study 11 cases (32.35%) of cases presented with injury to

spleen.The associated injuries included fracture of Left lower ribs in 3 cases

.27.27% .

Of the patients presented 3 patients were hemodynamically unstable

with B.P systolic below 90 mm of Hg and pulse rate greater than 120\mt .They

were resuscitated appropriately and taken up for laparotomy.

The commonest finding in all the patients were tenderness in the left

Hypochondrium which was present in nine patients . Most of the patients had

contusions or abrasions over the left hypochondrium.

Kehrs sign was present in 4 patients , ballance sign was present in

none.Bowel sounds were present in 8 cases .

Abdominal paracentesis was done in all cases and was positive in all

cases. X-ray chest and abdomen was taken in all hemodynamically stable

patients . It showed fracture ribs 6-9 in two patients and # 9th rib in one patient..

The diagnosis of splenic injury was confirmed by clinical examination,

the presence of haemoperitoneum which was confirmed by abdominal

paracentesis and ultrasonogram.

At laparotomy all the cases which were operated upon had Grade III

injuries in 7 cases Grade IV in 2 cases and Grade V in 1 case .Splenectomy was

53  

done in all cases, appropriate surgical procedures (ICD insertion) was done for

cases with hemothorax.

One patient expired pre operatively .He was hemodynamically unstable at

the time of admission and his condition was very poor and did not respond to

resuscitation.

54  

AN OPERATED CASE OF GRADE IV LACERATION SPLEEN

55  

Liver Injury:

Next to spleen liver is the commonest organ to be injured following

blunt abdominal trauma. In our study the incidence of liver injury was 8 cases

23.52% . The association of rib # with liver injury was 5 cases 62.5% .Three

patients were hemodynamically unstable .All patients were appropriately

resuscitated and were taken for laparotomy.

Tenderness and guarding in Right hypochondrium was present in 7& 4

cases respectively .Bowel sounds were heard in 6 patients . Contusion or

abrasions were present over right hypochondrium in all patients.

Abdominal paracentesis was positive in all cases. FAST missed a case of

Grade I liver laceration and wrongly attributed a case of renal injury having

associated liver laceration.

All patients were taken for laparotomy . 3 patients had Grade I injury , 4

patients had Grade II injury , 1 patient had Grade IV injury . Suture packing

with gel foam was done in all these 7 patients .

Postoperatively all patients with grade I ,II injuries recovered well ,

except one case which had prolonged ooze for one week the ooze stopped

gradually and he was doing well . Post operative fever was present in 6 patients

which settled with antibiotic treatment and drainage.

Another patient with Grade IV injury was treated by Pringle manoevre ,

resectional debridement of the devitalized portion of the liver by finger fracture

56  

technique. Omental pack was placed over the defect in the liver and the

peritoneal cavity was drained. Patient expired Postoperatively due to severity of

injuries.

GRADE IV LIVER LACERATION

57  

RENAL INJURIES:

The total no of renal injuries was 4 , right kidney was injured in three

cases and the left kidney in one case , All four cases were associated with RPH .

All patients presented with tenderness in flanks.Guarding \ Rigidity was

present in one case . Hematuria was present in all cases. Paracentesis was

positive in 2 cases. FAST revelaed Contusion of kidney in all cases & presence

of free fluid in morrisons pouch in three cases. Hence to rule out any expanding

hematoma and associated injuries patients were taken up for laparotomy

At laparotomy all renal injuries were of minor nature being contusion

involving the renal cortex . There was non expanding RPH in zone 2 right side

for 3 cases and non expanding RPH zone 2 left for one case . Since it was not

expanding Retroperitoneum was not opened . There was minor breach of

peritoneum with minimal free fluid in the pelvis in all cases.

There was no mortality in our study of four cases and in all cases

hematuria settled after 2 weeks and renal parameters were normal.

Bladder Injuries:

The total no of bladder injury in our study was 4 . All cases were

intraperitoneal rupture .These injuries were associated with fracture of superior

and inferior pubic rami. Once case was associated to have a Zone 3

Retroperitoneal hematoma .

Clinically patient presented with diffuse abdominal guarding and

tenderness in supra pubic region .Hematuria was present in three cases .

58  

Diagnostic paracentesis was positive for turbid fluid in three cases. USG

abdomen revealed presence of free fluid in all cases and presence of clots in the

urinary bladder.

At laparotomy the findings included rupture of bladder fundus in a case

and posterior aspect of bladder in two cases. In another case there was a small

pin hole size laceration in posterior aspect of bladder about 1 cm size with non

expanding zone 3 RPH .All cases were repaired using double layered closure

and placing SPC via a separate opening ..

BLADDER INJURY - REPAIR

59  

TRAUMATIC ILEAL PERFORATION

Bowel Injuries:

The total no of bowel injuries were 4 11.76% . Of these one case had

perforation of jejunum , two cases had perforation of ileum and one was a

perforation of duodenum . A case of ileal perforation had an associated # of

tibia.

All cases presented with guarding and rigidity at time of admission ,

tenderness was present diffusely in all patients , bowel sounds were absent in all

patients. All patients were hemodynamically stable .Xray showed air under

diaphragm in two cases (50%) . USG revealed presence of Free fluid in all cases

without any solid organ injury . Paracentesis was done and was positive for free

fluid in all cases.

60  

At laparotomy the perforation of duodenum was closed with a live

omental patch , the jejunal perforation was closed in two layers with inner vicryl

and outer silk . The ileal perforation margins were friable so resection

anastamosis was done .

Mesenteric Injury:

The mesenteric injuries were 4 cases in total . Mesenteric contusion in

jejunum was present in three cases and ileum was present in one case . The

mesenteric contusion in ileum was associated with Retroperitoneal hematoma in

zone 3 which was non expanding.

Clinically two patients presented with tenderness over umbilical and iliac

regions.Guarding was present in one case . Bowel sounds were present in two

cases . Diagnostic paracentesis was positive in one case for presence of blood .

USG revealed presence of minimal free fluid in pelvis in all cases .

At laparotomy the contusion of mesentery in jejunum was not associated

with any bowel pathology and the the bleeding stopped spontaneously . Hence

after securing perfect hemostasis closure with a tube drain was done . The

contusion in ileum was associated with segment of gangrene of ileum hence

resection anastamosis of ileum was done . The associated Retroperitoneal

hematoma in zone 3 was non expanding and hence was left as such .All patients

recovered well without complications .

61  

PROTOCOL FOR MANAGEMENT OF BLUNT INJURY ABDOMEN

PATIENTS WITH BLUNT ABDOMINAL TRAUMA

HAEMODYNAMICALLY UNSTABLE

FAST SCAN

POSITIVE OR EQUIVOCAL

LAPAROTOMY

NEGATIVE

RULE OUT OTHER ASSOCIATED INJURIES 

AND OBSERVE

REPEAT FAST OR            

EXPLOARATORY LAPAROTOMY

HAEMODYNAMICALLY STABLE

FAST SCAN

POSTIIVE

EXPLORATORY LAPAROTOMY

NEGATIVE

SERIAL OBSERVATION

CT ABDOMENREPEAT FAST

62  

CONCLUSION

1) The most commonly injured organ is spleen in blunt abdominal trauma

which is similar to other studies

2) RTA accounted for majority of cases of blunt injury abdomen which is

around 64.70%

3) Similar to many large series males are more often affected in blunt

abdominal injuries than females and middle aged persons are more often

affected than extremes of age

4) Commonest associated injuries occurred in our study was chest injury in

eight cases

5) FAST is rapid cheap noninvasive procedure used for screening in the

emergency ward itself while the patient is resuscitated.

6) Biochemical investigations are not of much help. The investigations only

complimentary to clinical diagnosis.

7) In the unstable trauma patient, a positive FAST eliminates the need for

further tests and indicates the necessity for abdominal exploration the

emergency ward itself while the patient is resuscitated.

8) Diagnostic paracentesis is a rapid , bedside tool for diagnosis

immediately at the bedside arrival of the patient.

9) Thorough initial clinical evaluation, repeated clinical examinations

monitoring vital signs are essential in minimizing the chance of missing

life threatening intra abdominal injuries.

10) The mortality in this study is related to severity of injuries . Severe the

grading of injury more is the mortality.

 

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PROFORMA

Name

Age

Sex

Occupation

Address

IP No.

Date of Discharge

First Aid Given: Yes/ no

Level of consciousness on admission

Intoxicated

Mode of Injury

Primary management in peripheral hospital

Whether passed urine /faeces after injury

Vital parameters on admission changes if any

Pulse

B.P

Respiration Rate

Temperature

Bowel Sound

Abdominal Girth

General Look: Normal / Pale /Cyanosed

Pain

Site

Type

On Coughing

Increasing / Decreasing

 

Shoulder Tip Pain: +/ -

Vomiting: +/-

Gaurding: +/-

Rigidity: +/-

Tenderness:

Site

Rebound

Type of abdominal injury

Abrasion / Laceration / ecchymosis / Bruises

Others

Other system injury

Associated bony injury

Lower ribs

Pelvis

Spine

Long bones

Perineal heamatomas

PR

NG Aspirations

Bladder catheterization

Details of blood transfusion

DPA: +/-

Blood

TC

Hb

Grouping & Typing

Plain X ray Abdomen

Chest

FAST

 

CT abdomen

Expected line of management

Purely conservative

Needs observation & delayed surgery if needed

Laprotomy details

Diaphragm Rectum

Liver Bladder

Spleen Urethra

Stomach Uterus

Small bowel Mesentry

Colon Pancreas

Omentum Retro peritoneum

Condition on discharge

 

MASTER CHART Sl. No NAME AGE\SEX MODE FAST LAPAROTOMY PROCEDURE

DONE 1 Muttiah 45\M RTA Free Fluid Mesentry contusion Drainage

2 Arivudai Dass 22\M Bull Gore Free Fluid Jejunal perforation Closure

3 Vel 33\m RTA Spleen injury laceration spleen Splenectomy 4 Namachivayam 17\M RTA Liver injury Laceration liver Gel foam packing 5 Seenivasan 47\M RTA Free Fluid ileal perforation Resect anastamose

6 Chinnathai 45\F Bull Gore Free Fluid ileal perforation Closure

7 Arulappan 36\M RTA Spleen injury laceration spleen Splenectomy 8 Pitchaipandy 20\M RTA Free Fluid Duo perforation Closure

9 Selva Sekaran 32\M ACC Fall Liver injury Laceration liver Gel foam packing

10 karthick 22\M RTA Spleen injury laceration spleen Splenectomy 11 Imayavaramban 32\M RTA Spleen injury laceration spleen Splenectomy 12 Babu 25\M RTA Free Fluid Bladder injury Closure with SPC

13 Gopalakrishnan 28\M ACC Fall Free Fluid Mesentry contusion Drainage

14 Arumugam 39\M ACC Fall Free Fluid Liver laceration Gel foam packing

15 Sukumaran 34\M RTA Spleen injury laceration spleen Splenectomy

16 Thangamuneeswaran 28\M Bull Gore Free Fluid Bladder injury Closure with SPC

17 kumar 14\M RTA Free Fluid Spleen laceration Splenectomy 18 Soosairaj 15\M RTA Free Fluid Bladder injury Closure with SPC 19 Jesuraj 28\M RTA Liver injury Laceration liver Gel foam packing 20 Rathina Velayutham 27\M RTA Spleen injury laceration spleen Splenectomy 21 Vinayakam 35\M RTA Liver injury Laceration liver Gel foam packing

22 Vettum perumal 37\M ACC Fall Free Fluid Spleen laceration Splenectomy

23 Balamurugan 23\M ACC Fall Liver injury Laceration liver Gel foam packing

24 Hariram 20\M Bull Gore Liver injury laceration liver Gel foam packing

25 Selvaraj 40\M RTA Free Fluid Bladder injury Closure with SPC 26 Subbaiyah 60\M RTA Free Fluid Kidney Drainage 27 Kanthappan 40\M RTA Free Fluid Mesentry contusion Drainage

28 Kulalamani 55\F Bull Gore Free Fluid Kidney Drainage

29 Irulappan 39\M ACC Fall Spleen injury Spleen laceration Splenectomy

30 Manikandan 41\M Bull Gore Free Fluid Kidney Drainage

31 Senthil 35\M RTA Spleen injury Spleen laceration Splenectomy 32 Sakthi 26\M RTA Spleen injury spleen laceration Splenectomy 33 Muthuraj 14\M RTA Free Fluid Kidney Drainage 34 Shakthi 28\M RTA Liver injury Laceration liver Hepatorraphy